=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780352708
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELSA LEE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2021
-----------------------------------------------------
Last Update Date | 09/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 NORTHERN BLVD STE 205
-----------------------------------------------------
City | GREAT NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11021-5112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-389-2283
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 505 NORTHERN BLVD STE 205
-----------------------------------------------------
City | GREAT NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11021-5112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | ELSA LEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 646-238-9228
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------